The Verdict on Vaping

Electronic cigarettes have been marketed as “healthier” alternatives to traditional cigarettes and as a good way to quit smoking. Only recently have people begun to look into the science behind these devices and ask the right questions. What exactly are electronic cigarettes? How do they work? Are they safer than tobacco cigarettes? Can they help me quit smoking? Unfortunately, the answers research is providing to some of these questions, especially when it comes to teens and young adults, are not what most people hope to hear.

The e-cigarette

Electronic cigarettes were invented in 2003 by Hon Lik, a Chinese pharmacist who was trying to quit smoking, and as of 2015, most were still made in China. Also known as electronic nicotine delivery systems (ENDS) and personal vaporizers, electronic or e-cigarettes are handheld, electrical devices designed to deliver nicotine to users in the form of vapor instead of smoke. They come in a variety of shapes, sizes, and styles, including cigars, pipes, and cigarette or pen look-a-likes. Most e-cigarettes have 3 main components. First, is the power source, which is usually a battery. Next, is the heating device, called an atomizer or vaporizer, which turns the liquid into an aerosol or vapor. Lastly is a cartridge or tank which holds the e-liquid and has a mouthpiece on one end. Sometimes the atomizer and cartridge are combined into a single unit called a cartomizer. As the user breathes into the mouthpiece, the heating device activates, and he or she then inhales or “vapes.”

The e-liquid

The liquid in an e-cigarette cartridge contains 4 main ingredients: nicotine, flavoring, propylene glycol, and glycerin. While the amount of nicotine in e-cigarettes varies greatly, a low level generally corresponds to 6 to 12 mg of nicotine, a medium level to 18 mg, a high to 24 mg, and very high to 36 mg. E-cigarettes taste like conventional cigarettes, but also come in a variety of flavorings from menthol to mocha dream. Currently, there are as many as 7,700 flavors on the market.2 Sweet flavors appeal particularly to young people.
Until August of 2016, the US Food and Drug Administration (FDA) did not regulate e-cigarettes, so there were no requirements for ingredient disclosure, warning labels, or youth access restriction. Partly as a consequence of FDA involvement, scientific research into the components of e-cigarette liquid as well as the health effects of e-cigarette use and exposure has increased. The findings reveal that the e-liquid usually contains not only nicotine, a highly addictive substance, but also benzene (which is found in car exhaust) and heavy metals, such as nickel, tin, and lead. Even an ingredient used in anti-freeze, diethylene glycol, has been identified in the e-liquid.3 Moreover, 75% of flavorings contain a chemical called diacetyl, which, when inhaled, has been linked to bronchiolitis obliterans, or permanent scarring of the airways in the lungs, and severe respiratory disease (Fig).1-3

The e-vapor

The real danger of vaping, however, may derive from the process that turns the liquid into a vapor. At a temperature of about 100 to 250°C (212 to 482°F), the chemical compounds inside the fluid break down and are converted into other chemicals. Scientists have examined the resulting mix and found both formaldehyde (a carcinogen or cancer-causing substance) and formaldehyde-releasing agents.1 Therefore, although traditional cigarettes contain over 4,000 chemicals— including 43 known cancer-causing compounds and 400 other toxins like arsenic, acetone (the active ingredient of nail polish remover), carbon monoxide, ammonia, and methanol (found in rocket fuel)—the risk of developing cancer from electronic cigarettes may be 15 times higher than from tobacco cigarettes, according to a report by Agence France-Presse. Moreover, like smoking, vaping can expose others to dangerous second-hand emissions (Fig).

Can e-cigarettes help me quit smoking?

It has been well established that cigarette smoking is harmful to nearly every system of the body and can cause a host of serious illnesses from emphysema and lung cancer to heart attack and stroke (Fig). Smoking is also a notoriously difficult habit to break: approximately 80% of would-be quitters will relapse within the first month. E-cigarettes have not only been promoted as safer than traditional cigarettes, but also as a means for smokers to quit. As there has been no evidence until recently that the devices can help traditional cigarette smokers stop smoking or even cut back, the FDA has been trying to evaluate and regulate this claim. E-cigarettes that contain nicotine levels lower than the 1mg of nicotine in tobacco cigarettes have been marketed with the idea that vaping small amounts of nicotine might help smokers quit. However, as consumers typically refill e-cigarette cartridges, they may offset any benefit from the reduced nicotine, exposing themselves to greater quantities than recommended.1 On the other hand, in 2014, the first Cochrane review—an independent, non-profit collaboration of researchers from more than 130 countries who work to produce credible and accessible health information without commercial sponsorship and other conflicts of interests—reported that, based on 2 randomized, controlled trials of more than 660 individuals conducted in England, e-cigarettes could increase the chance of smokers quitting: 9% of those using such devices stopped smoking for at least 6 months, compared with only 4% of those using e-cigarettes without nicotine. In a larger survey, University College London Professor of Health Psychology Robert West estimated that for every 10,000 people who use e-cigarettes to help them quit smoking, approximately 580 will quit. In 2015 alone, e-cigarettes may have helped about 18,000 smokers quit who might not have otherwise. Other studies, however, have revealed more modest results, cautioning that only 1 out of every 5 of those who attempt to quit smoking permanently by substituting vaping succeed.3 Furthermore, debates about whether e-cigarettes are more effective or safer than nicotine patches or other aids to quit smoking continue. Unlike pills and patches, the devices offer the advantage of mimicking the behavioral and psychological aspects of smoking; they provide a substitute for hand-to-mouth action and a coping mechanism for conditioned smokers.

Smoking trends

According to both the US Centers for Disease Control and Prevention and the FDA, electronic cigarette use now exceeds that of conventional cigarettes.3 Everyday usage is common, and many vapers are middle-aged males who also smoke. Among teens, e-cigarettes, and even marijuana, are more popular than tobacco cigarettes. A survey performed by the CDC found that while the total number of teen cigarette smokers has declined over the past 2 decades to 1.6 million, 1.3 million youth have taken up vaping.1 In fact, according to a recent FDA News Release on new tobacco regulation, between 2011 and 2015, e-cigarette use among high school students jumped from 1.5 to 16%, an increase of about 900%. This is a disturbing trend as e-cigarettes have not been proven to be healthier than regular cigarettes. Additionally, vaping can be a gateway to tobacco use for the younger generation. A study conducted by the National Center for Chronic Disease Prevention and Health Promotion revealed that US teens and young adults who have never smoked but have used e-cigarettes were 8.3 times more likely to begin smoking after just 1 year than those who have never vaped.3

Nicotine is not for teens

While nicotine is not a known carcinogen, it is a highly addictive substance that is lethal in high doses. In 2015, the American Association of Poison Control Centers reported 3,073 calls involving issues with e-cigarette devices and liquid nicotine. Moreover, nicotine can have long-term effects on brain development. This is largely because the brain’s prefrontal cortex (PFC), which is responsible for executive functions and attention performance, is one of the last areas to mature, continuing to develop until age 25. Consequently, when young people smoke, they increase the risk of developing impaired judgment, cognitive dysfunction, and attention deficits, as well as psychiatric and mood disorders. Smoking can also reduce impulse control in youths and alter the way they will make decisions as adults. Furthermore, nicotine use can lead to an increased risk of cardiovascular, respiratory, and gastrointestinal disorders as well as a decrease in immune response, which can negatively impact reproductive health (Fig).

The verdict

On December 8, 2016, the Surgeon General’s Office released “E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General,” which comprehensively reviewed the public health issue of e-cigarettes, particularly their impact on US teens and young adults. Surgeon General Vivek H. Murthy has dubbed the devices “a public health threat to America’s youth” that is putting a whole new generation at risk for nicotine addiction. Fortunately, however, the upward trend in e-cigarette use among high school seniors has recently begun to reverse with just 12% saying they have used e-cigarettes compared with 16% in 2015.3 E-cigarettes may help some people quit smoking, and due to variable nicotine and chemical contents of the e-liquid, some controversy remains about whether they can be less harmful than tobacco cigarettes. Still the verdict on vaping, especially for teens, is simple: if you haven’t started, don’t; if you have, quit.